Background. Cytomegalovirus (CMV) antiviral drug resistance constitutes an increasing challenge in transplantation. Foscarnet is usually proposed when resistance for ganciclovir is suspected, but its use is limited by its nephrotoxicity. Case Presentation. We report a case of multiresistant CMV disease in a kidney transplant recipient. Foscarnet was prescribed after ganciclovir treatment failure in a patient with two mutations in the UL97 viral gene. Foscarnet induced biopsy-proven kidney crystal precipitation that resulted in severe acute transplant failure and nephrotic syndrome. Despite a large decrease in immunosuppression, CMV disease was not controlled and a salvage therapy with Brincidofovir (BCV), which is an oral lipid conjugate of cidofovir with limited nephrotoxicity, was attempted. Clinical and virological remission was observed after a 21-day course of BCV, despite mild and reversible liver toxicity. However, a new relapse could not be effectively cured by BCV due to a new mutation in the UL54 gene, which is known to confer resistance to cidofovir. A new course of foscarnet finally resulted in prolonged CMV remission. Herein, we present a review of foscarnet nephropathy cases in solid-organ transplanted patients. Conclusions. This unique case highlights the potential benefit of BCV use during resistant CMV infection, although mutations in the UL54 gene may limit its therapeutic efficacy. These findings need to be confirmed in clinical trials.

Background and objectives Monoclonal gammopathies (MGs) with renal involvement can lead to ESRD caused by myeloma cast nephropathy (MCN), immunoglobulin light chain amyloidosis (ALA), or light chain deposition disease (LCDD). Few studies have focused on the prognosis of patients with MG on chronic dialysis. We evaluated the outcomes of patients with MG incident on chronic dialysis in France.Design, setting, participants, & measurements All incident patients registered in the Renal Epidemiology and Information Network Registry between 2002 and 2011 with ESRD caused by ALA, LCDD, or MCN were included. Patient's survival, censored for renal transplantation, renal recovery, and loss to follow-up, as well as renal outcomes were analyzed and compared with a control group. Risk factors and causes of death were analyzed.Results We included 1459 patients, comprising 265 (18%) patients with ALA, 334 (23%) patients with LCDD, and 861 (59%) patients with MCN. Median age was 72 years, and 56% were men. Median follow-up was 13.1 months. Renal recovery was observed in 9.1% of patients and more frequent after 2006. Kidney transplantation was rare in this population (2.3%). Among 1272 patients who remained on dialysis, 67% died. Median survival on dialysis was 18.3 months. Main causes of death were malignancies (34.4%), cardiovascular diseases (18%), infections (13.3%), and cachexia (5.2%). Independent risk factors of death were age (hazard ratio [HR], 1.03 per year increase; 95% confidence interval [95% CI], 1.02 to 1.03), frailty (HR, 1.93; 95% CI, 1.58 to 2.36), congestive heart failure (HR, 1.54; 95% CI, 1.23 to 1.93), and dialysis initiation on a central catheter (HR, 1.40; 95% CI, 1.11 to 1.75). Factors associated with a lower risk of death were year of dialysis initiation (HR, 0.95 per year increase; 95% CI, 0.91 to 0.99) and high BP (HR, 0.80; 95% CI, 0.67 to 0.97).Conclusions Survival of patients with ALA, LCDD, or MCN on chronic dialysis is poor but has improved over time. Progressive malignancy is the main cause of death in this population. Renal recovery has increased since 2006.

Les anticorps antiphospholipides (APL) sont une famille hétérogène d’auto-anticorps plasmatiques qui reconnaissent des épitopes antigéniques portés par des phospholipoprotéines. La prévalence des APL chez les insuffisants rénaux chroniques est de 11 à 37 % selon les études. Certains auteurs ont décrit une association entre la présence d’un APL et la thrombose de l’abord vasculaire de dialyse (AV) mais ces études anciennes sont de faible effectif. Dans cette étude monocentrique rétrospective, nous avons déterminé la prévalence des APL chez 192 patients en hémodialyse, analysé les facteurs de risque d’avoir un APL et recherché si la présence d’un APL était associée aux antécédents de thrombose de l’AV. Au moins un APL a été retrouvé chez 38 patients (19,8 %). Parmi eux, 74 % (n=28) avaient un anticoagulant circulant lupique (ACC) isolé. L’âge médian des patients ayant un APL était de 68,1 ans et celui des patients qui n’en avaient pas était de 71,3 ans (p=0,02). Un antécédent de tabagisme était associé à la présence d’APL : 35,5 % des patients avec un APL avaient un antécédent de tabagisme et 18,3 % des patients sans APL (p=0,04). En analyse multivariée, les 2 facteurs indépendamment associés à un antécédent de thrombose de l’AV étaient l’âge (HR [IC 95 %]=1,04 [1,02–1,06] ; p=0,001) et la présence d’un APL (HR [IC 95 %]=3,03 [1,69–4,42] ; p<10–3). En conclusion, la prévalence des APL chez les patients dialysés reste élevée malgré l’amélioration des techniques de dialyse : démocratisation de l’hémodiafiltration, amélioration de la biocompatibilité, eau ultra-pure. Les facteurs associés à la présence d’un APL sont un âge jeune et un antécédent de tabagisme. La présence d’un APL, en particulier de type ACC, est associée de façon indépendante à la survenue d’une thrombose de l’AV.

Pericardial effusion in uremic patients (UPE) was first described by R. Bright in 1836. It is generally agreed that patients require emergency pericardial drainage when tamponade signs are present, but in patients with no tamponade the optimal timing for drainage remains unclear.

Antiphospholipid antibodies (APL) are a heterogeneous family of auto-antibodies that recognize phospholipoproteins bound antigenic epitopes. APL prevalence in patients on chronic hemodialysis ranges from 11 to 37% in the literature. The association of APL with hemodialysis vascular access (VA) thrombosis has already been reported in small studies. In this single center and retrospective study, we defined the APL prevalence and APL risk factors in a large cohort of 192 hemodialysis patients. The association between history of VA thrombosis and APL presence was also analyzed. At least one type of APL was found in 38 patients (19.8%) of which 74%(n = 28) had only lupus anticoagulant. Median age of APL positive patients was 68.1 years vs 71.3 years in APL negative patients (P = 0.02). Smoking history was associated with APL presence: 35.5% of APL positive patients had a smoking history vs only 18.3% of APL negative patients (P = 0.04). The multivariate analysis showed an association between the history of VA thrombosis and patient age (HR [IC 95%] = 1.04 [1.02-1.06]; P = 0.001) or APL presence (HR [IC 95%] = 3.03[1.69-4.42]; P < 10(-3)). In conclusion, the prevalence of APL in hemodialysis patients remains high despite hemodialysis techniques improvement: hemodiafiltration, biocompatibility improvements, ultrapure dialysis water. We report that a younger age and past history of smoking are associated with an increased risk of APL presence. The presence of APL, especially lupus anticoagulant, is associated to VA thrombosis in hemodialysis patients. (C) 2014 Association Societe de nephrologie. Published by Elsevier Masson SAS. All rights reserved.